In this together: why clinically led commissioning will rely on collaboration

Making the rapid transition towards a clinically-led health service, where clinicians are empowered to make commissioning decisions previously afforded to PCTs, undoubtedly throws up significant organisational and cultural challenges for the NHS.

Overcoming them not only requires a new form of clinical leadership, it demands a collaborative and inclusive approach that captures voices from across the entire local clinical network – and gives clinicians the autonomy, the freedom and, crucially, the information to make innovative and beneficial commissioning decisions that improve patient care.

At a time when many within the NHS are searching for best practice examples to help them manage cultural changes, the collaborative environment being forged at Bexley Care Trust provides clear evidence that unleashing the “wisdom of clinicians” can act as a catalyst for innovation, efficiencies and improvements in the quality of patient care.

Bexley Care Trust is part of the NHS South East London cluster and commissions health and social care to around 220,000 patients in the London Borough of Bexley. It has gained local and national recognition for its proactive and innovative approach to redesigning clinical services in the region.

“Proper clinical leadership is undoubtedly what is required to have a strong, sustainable and well-run health economy with good patient outcomes,” says Dr Joanne Medhurst, joint managing director of Bexley Business Support Unit. “But progress is not about having heroic transformational leadership. For clinical commissioning to succeed, we need a distributive leadership model which faces in many directions and listens, collects and helps construct the wisdom of groups not the wisdom of individuals. It’s about establishing a joint vision and delivering it together.”

Bexley Care Trust’s collaborative model is spearheaded by its clinical executive committee and its ‘clinical cabinet’.  Bexley’s GPs work in partnership with consultants, practice managers, local nurses and pharmacists – as well as patients – to drive improvements to health services.

“It’s about engaging with the wider network, working with practices, going to localities, listening to the group – including our hospital consultants and our local authority – and trying to find out what is best for our local population. It’s a much more mature model of leadership,” says Dr Medhurst.

The multidisciplinary approach has served Bexley well. But its success is underpinned and supported by an informatics system that enables its clinicians to make commissioning decisions based on robust and reliable data.

“To empower groups of GPs, practice managers and HCPs, they must first understand their landscape,” says Dr Medhurst. “Good informatics allows you to have an informed debate rather than an anecdotal one; you can look at outcomes, referral patterns and prescribing trends, and then discuss them through the wider network. Too many GPs are terribly disempowered because they don’t have this information at their fingertips, and go down blind alleys because they don’t really know where to focus. Technology is part of the solution. While on its own it won’t dictate the vision or drive behaviour, it can help inform the thinking that determines the vision, culture and behaviour.”

Bexley Care Trust has been working in partnership with healthcare data intelligence specialist MedeAnalytics to develop an informatics system to support clinical commissioning since 2009. In July this year the company launched its analytics solution Clinical Commissioner, having successfully piloted it with Bexley from 2010.

The system comprises a suite of locally adaptable reporting solutions that can provide meaningful data to help GPs make commissioning decisions. During the pilot phase, Bexley had identified a range of analytics needs it believed would empower clinicians. These included developing informatics around referral management, prescribing patterns, GP spend, vital signs data and QOF.

The main focus has been on non-elective admission avoidance – keeping patients out of hospitals and, in the process, reducing Bexley’s bill from the region’s five acute trusts. “It’s largely about helping our GPs in terms of case management – and the technology is absolutely core to it,” says Darren Blake, head of GP practice support at Bexley Care Trust.

“Every month, each of our GP practices gets sent a list of patients in a register. This list is sourced from a combination of historical ‘frequent flyers’, along with patients identified through our own risk stratification tool which assesses the predictive risk of a patient being admitted to hospital.”

GPs are asked to review the list to determine whether they can influence or avoid the admission. “The challenge is to keep patients in primary care rather than have them go to A&E. GPs focus on the ones they think they can influence – and we have integrated team meetings to determine the best care plan to help avoid the non-elective admission. The Mede system helps to ensure we have that multidisciplinary discussion to give patients the best chance of avoiding hospital.”

In the six months between April and September 2011, the number of “GP influenced” non-elective admissions has reduced by 289 spells compared with the same period in 2010. This has yielded indicative cost-savings (based on acute billing in the prior year) of £267,000 across all the practices in Bexley, and a reduction in non-elective admissions of some 200 patients.

Bexley also uses the Clinical Commissioner tool to monitor its QIPP schemes – assessing whether its community schemes are delivering the required productivity and quality gains.

“The technology really does equip GPs for clinical commissioning. Having access to this kind of information is absolutely core and it’s practically impossible to do commissioning without it,” says Mr Blake.

“It’s about arming GPs with valuable data – and they are getting used to it. It is now a way of life, and you don’t get through a day without speaking about it in one form or another. But for them the focus is not on pounds and pence, it’s about clinical improvement and the betterment of patient care. The system is helping them to deliver that.”

The data at the heart of the system is vital to establishing performance and identifying needs. But it is only one component of a bigger picture.

“Technology is not where the solution to a problem starts, but it can certainly help craft the question,” says Dr Medhurst. “If I was parachuted into another trust, I would first need to see their data – the prescribing trends and referral rates. I would put all of it together and it would describe the problem. The solution would be about creating the story and setting the vision for the future, which can be crafted together as a group. Technology enables you to create factually-based stories, rather than anecdotal ones.”